A group of physicians, writers, and educators sits around a conference table in a busy medical school, eating hurried lunches, coordinating course materials for medical students, reviewing with excitement or concern what just happened in their first-year medical interviewing courses. More people gather, and the room quiets. Today, the novelist on the faculty reminds them, they are reading “Aquarium,” a personal essay written by writer Aleksandar Hemon who has lost his baby daughter to brain cancer. The mood in the room shifts from light camaraderie to an attentive sense of purpose. “I had such a hard time reading this,” a seasoned family physician sighs. “It made me want to run home and pick up my baby,” offers the hospitalist.

As the conversation develops, the novelist draws the group’s attention to the essay’s title and its governing image, an important metaphor for his experience with illness and loss. “The whole thing is about an aquarium,” an internist and literary scholar offers. “You feel very much like an outsider reading this,” admits a pediatrician.

After some discussion, the novelist offers a writing prompt: Describe an aquarium that you yourself have been in. The group members take out pen and paper and, heads bowed, write intently for 4 minutes. When the time is up, many offer to read their work. Some read aloud descriptions of experiences with literal aquariums, marveling at the foreignness of aquatic life. A psychiatrist and a general internist each read aloud what they wrote about-times when they felt isolated in family or work and unable to truly communicate with those around them. Some wrote about feeling that, as doctors, they are inside an aquarium; others wrote about the experience of being on the outside. “The whole patient experience is like being in a fishbowl,” reflects a pediatrician, “and in the story, the doctors are in a fishbowl too.” The internist and literary scholar replies, “But this story is like instructions about how not to be marooned. It gives a glimpse into that fishbowl, but also says and then you can write. It opens up a way to talk about and then use the imagination and the power of words.”

This session is a typical example of the kind of work this group does every week. They are medical educators, the faculty of Foundations of Clinical Medicine (Columbia’s “doctoring” course) who employ the techniques of narrative medicine to sharpen their clinical skills, deepen their teaching, and reflect on their work. Narrative medicine developed out of the integration of medicine and literary studies to fortify clinical practice with the narrative competence to recognize, absorb, metabolize, interpret, and be moved by the stories of illness. Its unifying tenet is that the giving and receiving of accounts of self are the central events in health care—whether the account is given by a patient, family member, student, clinician, or members of the lay public and whether it is received by a doctor in the office, a circle of peers in a teaching session, a multidisciplinary team meeting in a clinic, or a Congressional hearing about health reform. Although arising only in 2000 from earlier efforts in humanities and medicine and primary care medicine, narrative medicine has spread quickly first at its home at Columbia University and then throughout the United States and abroad. Synthesizing theories and methods from the humanities, the social sciences, and the behavioral sciences, narrative medicine models a bridge among disciplines and, more importantly, supports the interior integration of cognitive, behavioral, imaginative, aesthetic, and affective states to which the effective clinician aspires.

Narrative medicine unfolds in three broad and simultaneous movements—attention, representation, and affiliation. These movements conceptualize and then guide a clinical and teaching practice that can establish contact with self, patients, students, colleagues, and the public that medicine serves. We will first define these movements and then follow with real-life examples.

Attention is that state of receptivity whereby a listener or witness or reader can receive the account given by another. To attain the state of attention, the receiver focuses closely and deeply on the person giving an account, whether that person is a patient, a student, a novelist, a poet, or even a painter or a composer. The receiver does not efface himself or herself but rather offers the contours of the self as a container for what is given by the other. Combining mindfulness with curiosity, the receiver captures all that the other transmits, squandering no word or silence or gesture or mood from the evidence that emerges from the encounter.

Representation includes the means by which any attentive witness confers form on what is received. Typically this is done with language as one writes a story or a vignette or a progress note to capture that which has been received from the other. (Although visual representations can also be made, we restrict ourselves here to written representations.) What is represented can be read—by the writer, by the subject of the representation, or by others involved in the clinical process. Because, as psychotherapist Hans Loewald suggests, writing is a sensorimotor act that transforms the immaterial into the material, it allows the writer to communicate what was not known until the writing to self and then to others.

Affiliation is the ultimate goal of any clinical act—affiliation between patient and clinician, between clinician and colleagues, between clinician-teacher and student, and between health care professionals and the public we serve. Robust affiliation provides the grounds for any event of healing.

These movements intensify one another, attention fueling the capacity to represent, representation fortifying the capacity to attend, and both of them spiraling toward affiliation. Doctor and patient write their way through clinical events. Medical students write reflective essays about early clinical experience, and their teachers receive them with newly developed skills in close reading. Patients and clinicians share writing groups to write about their lived experiences with illness. Multidisciplinary teams meet on the wards or the clinics to develop their own capacity to collaborate and unite. These methods permit us to get under the distinctions that typically isolate us from one another and bring us, in common, onto the grounds of human suffering and the desire to lessen that suffering.

Querying all faculty of Columbia’s Foundations of Clinical Medicine course, we compiled a table of goals that have been accomplished in clinical practice through the use of narrative methods (see Table 45-1). Selections from our respondents’ accounts of accomplishing some of these goals in practice thicken the descriptions of our listed goals. We categorize these goals according to the three movements of narrative medicine, although it is easily seen how these movements converge and occur simultaneously.

Attention

Representation